Teamsters Joint Council No - tjc83funds.org

1 Teamsters Joint Council No. 83 of Virginia Health & Welfare and Pension Funds 8814 Fargo Road Suite 200 Richmond, VA 23229 Phone (804) 282-3131 800-852-0806 Fax (804) 288-3530 Email: Continuance Form Please note: No further disability will be paid until the appropriate section of this form is completed and returned to the Fund Office. Part 1: If you continue to be disabled, an up-to-date out of work excuse or Part 1 of this form must be completed by your physician. 's full name _____ SSN or UID _____2. Nature of sickness or injury this work related? Yes No Date of first treatment of most recent treatment _____5. The patient has been continuously disabled (unable to work) from _____ and should beable to return to work on _____ (Please give an approximate date if possible).

2 S Name (please print) _____ Phone 's Signature:_____ Date _____Part 2: If you have returned to work, this section must be completed by your employer. Employee's Full Name_____ SSN or UID:_____ Name of Company _____ Phone No. _____ Date Returned to Work _____ Employer s Signature _____ Position_____ Date_____ For Fund Office Use Only Inc. _____ Date: _____ Pd from _____ through _____ By: _____ Claim # _____ Follow up sent Yes No